Physicians' Characteristics Associated with Their Attitude to Family Presence during Adult Cardiopulmonary Resuscitation.

Healthcare providers have disparate views of family presence during cardiopulmonary resuscitation; however, the attitudes of physicians have not been investigated systematically. This study investigates the patterns and determinants of physicians' attitudes to FP during cardiopulmonary resuscitation in Saudi Arabia. A cross-sectional design was applied, where a sample of 1000 physicians was surveyed using a structured questionnaire. The study was conducted in the southern region of Saudi Arabia for over 11 months (February 2014-December 2014). The collected data was analyzed using the Pearson chi-square test. Spearman's correlation analysis and chi-square test of independence were used for the analysis of physicians' characteristics with their willingness to allow FP. 80% of physicians opposed FP during cardiopulmonary resuscitation. The majority of them believed that FP could lead to decreased bedside space, staff distraction, performance anxiety, interference with patient care, and breach of privacy. They also highlight FP to result in difficulty concerning stopping a futile cardiopulmonary resuscitation, psychological trauma to family members, professional stress among staff, and malpractice litigations. 77.9% mostly disagreed that FP could be useful in allaying family anxiety about the condition of the patient or removing their doubts about the care provided, improving family support and participation in patient care, or enhancing staff professionalism. Various concerns exist for FP during adult cardiopulmonary resuscitation, which must be catered when planning for FP execution.

Role of antihypertensive therapy in mild to moderate pregnancy-induced hypertension: a prospective randomized study comparing labetalol with alpha methyldopa.

BACKGROUND: Pregnancy-induced hypertension (PIH) is associated with adverse fetal and maternal outcome. The role of medication to control blood pressure (BP) in mild to moderate PIH is controversial. AIMS: We conducted a prospective study to investigate whether pharmacological treatment of mild to moderate PIH is effective in improving maternal and fetal outcomes. METHODS: A total of 150 consecutive pregnant women without proteinuria and with physician-recorded systolic BP of 140-160 mmHg and/or diastolic BP of 90-105 mmHg on two occasions ≥6 h apart between 20 and 38 weeks of gestation were randomly allocated to receive either labetalol or methyldopa (50 patients each) plus standard care (treatment group) or only standard care (50 patients) (control group). RESULTS AND CONCLUSIONS: As compared to the control group, the treatment group had lower rates of severe PIH (28% vs. 10%, P = 0.005), proteinuria (28% vs. 12%, P = 0.016), hospitalization before term (28% vs. 14%, P = 0.041), and delivery by cesarean section (38% vs. 22%, P = 0.042). In a multivariable logistic regression model that adjusted for maternal age, weight, parity, previous PIH, and baseline hemoglobin, resting heart rate, and BP levels, antihypertensive therapy was associated with a lower incidence of adverse maternal events (P = 0.011). Compared to the control group, the treatment group had lower incidence of SGA babies (40% vs. 23%, P = 0.033), preterm birth (36% vs. 14%, P = 0.002), and admission to neonatal unit (30% vs. 15%, P = 0.036). After adjustment for maternal age, weight, baseline hemoglobin, resting heart rate, BP level, parity and previous history of PIH, fetal death, preterm delivery or SGA baby, antihypertensive therapy was associated with a lower incidence of adverse perinatal events (P = 0.016). Maternal and perinatal mortality rates were not significantly different between treatment and control groups. In conclusion, pharmacological treatment of mild to moderate PIH is associated with lower rate of some maternal and fetal-neonatal non-fatal adverse events compared to no routine use of antihypertensive therapy.

Brachial-ankle pulse wave velocity is associated with walking distance in patients referred for peripheral arterial disease evaluation.

OBJECTIVE: Impaired functional capacity predicts morbidity and increased mortality in patients with PAD. We hypothesized that brachial-ankle pulse wave velocity (baPWV), a measure of arterial stiffness, is associated with functional capacity in patients undergoing noninvasive evaluation for peripheral arterial disease (PAD). METHODS: We studied 114 patients (age 68+/-10 years) referred to Mayo Clinic's noninvasive vascular laboratory. Functional capacity was estimated in terms of distance walked in 5 min on a treadmill at a speed of 1.0-2.0 mph. Ankle-brachial index (ABI) was obtained with Doppler method before and 1 min after exercise. baPWV was estimated noninvasively using an oscillometric device. The association of baPWV with walking distance was assessed using accelerated failure time and Cox proportional-hazards models. RESULTS: The mean baPWV was higher in patients who were unable to complete the walk test compared to those who successfully completed the test (P=0.008). Higher baPWV was associated with a lower walking distance after adjustment for heart rate, mean arterial pressure, and cardiovascular risk factors (P=0.017) and after additional adjustment for pulse pressure (P=0.034) and ABI (P=0.030). Higher baPWV was associated with failure to complete the treadmill walk test, after adjustment for heart rate, mean arterial pressure, and cardiovascular risk factors (P=0.025) and after additional adjustment for pulse pressure (P=0.041) and ABI (P=0.039). CONCLUSION: Increased baPWV, a measure of arterial stiffness, is associated with impaired functional capacity in patients undergoing evaluation for PAD.

Forearm vascular reactivity and arterial stiffness in asymptomatic adults from the community.

Vascular reactivity may affect the stiffness characteristics of the arterial wall. We investigated the association between forearm microcirculatory and conduit artery function and measures of arterial stiffness in 527 asymptomatic non-Hispanic white adults without known cardiovascular disease. High-resolution ultrasonography of the brachial artery (ba) was performed to assess forearm microcirculatory function (ba blood flow velocity, local shear stress, and forearm vascular resistance at rest and during reactive hyperemia) and conduit artery function (ba flow-mediated dilatation [baFMD] and ba nitroglycerin-mediated dilatation [baNMD]). Arterial stiffness was assessed by cuff-derived brachial pulse pressure and aortic pulse wave velocity (aPWV) measured by applanation tonometry. In regression analyses that adjusted for heart rate, mean arterial pressure, height, cardiovascular risk factors, and hypertension medication and statin use, higher baseline ba systolic velocity and systolic shear stress were associated with greater pulse pressure (P=0.0002 and P=0.006, respectively) and higher aPWV (each P<0.0001). During hyperemia, lower ba mean velocity and lower mean shear stress were associated with higher pulse pressure (P=0.045 and P=0.036, respectively), whereas both systolic and mean velocity (P<0.0001 and P=0.002, respectively) and systolic and mean shear stress (P<0.0001 and P=0.003, respectively) were inversely associated with aPWV. baFMD was not associated with pulse pressure but was inversely associated with aPWV (P=0.011). baNMD was inversely associated with pulse pressure (P=0.0002) and aPWV (P=0.008). Our findings demonstrate that impaired forearm microvascular function (in the form of elevated resting blood flow velocity and impaired flow reserve) and impaired brachial artery reactivity are associated with increased arterial stiffness.

Association of plasma resistin with glomerular filtration rate and albuminuria in hypertensive adults.

Resistin, a recently discovered proinflammatory cytokine, has been variably associated with insulin resistance, inflammation, and renal dysfunction. We investigated the association of plasma resistin with estimated glomerular filtration rate and albuminuria in 1575 hypertensive adults without known coronary heart disease or stroke (857 blacks and 718 non-Hispanic whites). Resistin was measured by a solid phase sandwich immunoassay, estimated glomerular filtration rate was estimated from serum creatinine, and albuminuria was expressed as urine albumin:creatinine ratio. After adjustment for coronary heart disease risk factors (age, sex, body mass index, smoking history, systolic blood pressure, diabetes, and total and high-density lipoprotein cholesterol) and use of renin-angiotensin blockers and statins, higher plasma resistin levels were associated with lower estimated glomerular filtration rate in both ethnic groups (each P<0.0001); the association remained significant after further adjustment for a marker of insulin resistance (homeostasis model assessment for insulin resistance) and a marker of inflammation (plasma C-reactive protein) and was seen in subjects with and without diabetes (each P<0.0001) in both ethnic groups. Higher plasma resistin levels were associated with a higher urine albumin:creatinine ratio in black subjects with diabetes (P<0.0001) and non-Hispanic white subjects with diabetes (P=0.032), independent of coronary heart disease risk factors, hypertension medication use, and statin use; the association remained significant after additional adjustment for homeostasis model assessment for insulin resistance and C-reactive protein. In adults with hypertension, higher circulating resistin levels were associated with a lower estimated glomerular filtration rate and with increased urine albumin:creatinine ratio in the presence of concomitant diabetes. This association was independent of coronary heart disease risk factors and markers of insulin resistance and inflammation.

Association of cardiovascular risk factors with microvascular and conduit artery function in hypertensive subjects.

BACKGROUND: Alterations in microvascular and conduit artery function contribute to target organ damage in hypertension. We investigated the association of cardiovascular (CV) risk factors with microvascular and conduit artery function in hypertensive subjects. METHODS: Participants included 504 hypertensives (aged 62.1 +/- 9.8 years, 42% men) from the community, without history of symptomatic CV disease. Brachial artery ultrasound was performed to measure forearm blood flow (FBF) at rest and during reactive hyperemia (markers of microvascular function) and flow-mediated dilatation (FMD) of the brachial artery (a marker of conduit artery endothelial function). The association of conventional and novel (homocysteine, C-reactive protein, fibrinogen, and lipoprotein a CV risk factors with microvascular function and FMD was tested in multivariable regression models. RESULTS: Variables independently associated with higher resting FBF were male sex, higher body mass index (BMI), smoking, and lower HDL-cholesterol; variables associated with lower hyperemic FBF included greater age, female sex, and diabetes. Higher plasma homocysteine was associated with lower hyperemic FBF in obese subjects (P for log homocysteine x BMI interaction = .0008). Variables independently associated with lower FMD were greater age, sex gender, history of smoking, and not using statins. Higher homocysteine was associated with lower FMD in subjects with higher systolic blood pressure (P for interaction = .0004). Hyperemic flow velocity was independently associated with FMD (P = .0006), but its inclusion as a covariate did not influence the association of CV risk factors with FMD. CONCLUSIONS: In asymptomatic subjects with essential hypertension, select CV risk factors were associated with microvascular and conduit artery function. Furthermore, the association of CV risk factors with conduit artery function appeared to be independent of downstream microvascular function.

Arterial ultrasonography and tonometry as adjuncts to cardiovascular risk stratification.

Myocardial infarction and stroke often occur without prior warning in asymptomatic individuals. Identifying individuals at risk is important for cost-effective use of preventive therapies. Algorithms based on risk factors statistically associated with cardiovascular events classify individuals into high-risk, intermediate-risk, or low-risk categories. However, more than one-third of adults in the U.S. are in the intermediate-risk category, and decisions regarding therapy are challenging in this subset. Testing for alterations in arterial function and structure that predate cardiovascular events may help refine cardiovascular risk assessment in the intermediate-risk group and identify candidates for aggressive therapy. Vascular ultrasonography and tonometry are promising test modalities for assessment of arterial function and structure in asymptomatic subjects. Several prospective studies have shown that measures of arterial function and structure provide prognostic information incremental to conventional risk factors. Standardization of methodology and establishment of quality control standards in the performance of these tests could facilitate their integration into clinical practice as adjuncts to existing cardiovascular risk stratification algorithms.

Brachial artery diameter and vasodilator response to nitroglycerine, but not flow-mediated dilatation, are associated with the presence and quantity of coronary artery calcium in asymptomatic adults.

In the present study, we investigated whether measures of brachial artery reactivity were associated with the presence and extent of subclinical coronary atherosclerosis in asymptomatic adults. Electron beam computed tomography was employed to assess the presence and quantity of CAC (coronary artery calcium) in 441 participants (mean age, 61 years; 49% men) without prior history of CHD (coronary heart disease) or stroke, and CAC score was calculated using the method described by Agatston and co-workers [(1990) J. Am. Coll. Cardiol. 15, 827-832] High-resolution ultrasound was employed to measure BAD (brachial artery diameter), FMD (flow-mediated dilatation) and NMD (nitroglycerine-mediated dilatation). CAC score and FMD were log-transformed after adding 1 to reduce skewness. Multivariable logistic and linear regression models based on generalized estimating equations were used to assess whether BAD, FMD and NMD were each independently associated with the presence and quantity of CAC after adjustment for CHD risk factors and use of statin and hypertension medication. CAC was detectable in 64% of participants. After adjustment for age and sex, FMD was not correlated (r=-0.06; P=0.27), BAD was positively correlated (r=0.16; P=0.004) and NMD was inversely correlated in a borderline significant manner (r=-0.10; P=0.084) with log(CAC+1). In multivariable logistic regression analyses, FMD was not associated, whereas higher BAD (P=0.021) and lower NMD (P=0.030) were independently associated with the presence of CAC. In multivariable linear regression analyses, higher BAD (P=0.004) and lower NMD (P=0.016), but not FMD, were independently associated with log(CAC+1). We conclude that greater diameter of the brachial artery and lower vasodilator response to nitroglycerine, but not FMD, are associated with subclinical coronary atherosclerosis.